Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the clinical status of two residents. For one resident with a neurogenic bladder who used an indwelling catheter, the MDS inaccurately coded the resident as always incontinent of bladder, rather than using the appropriate coding for catheter use. Observation confirmed the presence of the catheter, and the MDS Coordinator acknowledged the error, stating that the incontinence status should not have been marked as always incontinent for a resident with a catheter. For another resident, the MDS assessment recorded a high mood score indicating significant depressive symptoms, including poor appetite, low self-esteem, and difficulty concentrating. The assessment also documented the use of an antidepressant medication but failed to indicate a diagnosis of depression, despite a physician's order for antidepressant treatment specifically for depression. The MDS Coordinator confirmed that the resident should have been identified with a depression diagnosis on the MDS assessment.